Reconstruction of massive tibial defect caused by osteomyelitis using induced membrane followed by trifocal bone transport technique: a retrospective study and our experience

Objective To evaluate clinical outcomes of the application of induced membrane followed by trifocal bone transport technique in the treatment of massive tibial defect caused by osteomyelitis. Method A total of 18 eligible patients with tibial defect > 6 cm caused by osteomyelitis who were admitted to our institution from January 2010 to January 2016 and treated by induced membrane followed by trifocal bone transport technique. There were 12 male and 6 females with an average age of 40.4 years old. A detailed demographic data (age, sex, etiology, previous operation time, defect size and location, interval from Masquelet technique to trifocal bone transport technique, external fixation index (EFI), duration of regenerate consolidation and docking union) were collected, bone and functional outcomes were evaluated by Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system. Complications during and in the period of follow up were recorded and evaluated by Paley classification at a minimum follow-up of 2 years. Results The etiology include posttraumatic osteomyelitis in 13 cases and primary osteomyelitis in 5 cases. An average of previous operation time was 3.4 times. Mean tibial defect after radical debridement was 6.8 cm. An average interval duration from formation of induced membrane to trifocal bone transport was 4.8 weeks. An average of EFI was 37.1 days/cm, the duration of regenerate consolidation and docking union were 124.7 days and 186.4 days, respectively. An average time of follow-up after removal of external fixator was 28.5 month without recurrence of osteomyelitis. The bony outcome was excellent in 6 cases, good in 8 cases, fair in 3 cases and poor in 1 case, and functional outcome was excellent in 4 cases, good in 10 cases, fair in 2 cases and poor in 2 cases. The most common complication was pin tract infection which occurred in 15 cases and there were no major complications such as nerve or vascular injury. Conclusion Massive tibial defect caused by osteomyelitis can be successfully treated first stage using induced membrane followed by second stage using trifocal bone transport technique, which is an effective method in terms of radical elimination of osteomyelitis with expected clinical outcomes.

Bone Defects in Tibia Managed by the Bifocal Versus Trifocal Bone Transport Technique

Background: The purpose of this study was to evaluate the clinical effectiveness and determine the differences, if any, between trifocal and bifocal bone transport technique in the reconstruction of long segmental tibial bone defects caused by infection using a monolateral rail external fixator. Methods: A total of 53 consecutive patients with long segmental tibial bone defects caused by infection and treated by monolateral rail external fixator in our department were retrospectively collected and analyzed from January 2013 to April 2019, including 39 males and 14 females with an average age of 38.8±12.4 years (range 19 to 65 years). 32 patients were treated by bifocal bone transport (BFT) technique, and the other 21 patients were managed by trifocal bone transport (TFT) technique. The demographic data, operation duration, docking time, external fixation time, and external fixation index were documented and analyzed. Difficulties that occur during the treatment were classified according to Paley. The clinical outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov criteria (ASAMI) at the last clinical visit.Results: All patients achieved an infection-free union finally, and there was no significant difference between the two groups in demographic data and both ASAMI bone and functional scores (P>0.05). The mean defect size and operation duration in TFT (9.4±1.5 cm, 161.9±8.9 minutes) were larger than that in BFT (7.8±1.8 cm, 122.5±11.2 minutes) (P<0.05). The mean docking time, external fixation time, and external fixation index in TFT (65.9±10.8 days, 328.0±57.2 days, 34.8±2.1 days/cm) were all less than those in BFT (96.8±22.6 days, 474.5±103.2 days, 60.8±1.9 days/cm) (P<0.05). Difficulties and complications were more prevalent in the BFT group, while less in the TFT group (P<0.05). Conclusions: Both the trifocal and bifocal bone transport technique in the reconstruction of long segmental tibial bone defects caused by infection using a monolateral rail external fixator achieve satisfactory clinical outcomes. The trifocal bone transport technique can significantly decrease the docking time, external fixation time, external fixation index, difficulties, and complications compared with the bifocal bone transport technique.

Efficacy of trifocal versus bifocal bone transport on large tibial bone defect: a systematic review and meta-analysis

One of the most common long-term complication of chronic osteomyelitis of tibia is segmental bone loss. One of the methods to manage the segmental bone loss in osteomyelitis is bone transport technique, which is able to reconstruct a defect of more than 6 cm. This paper aims to systematically review and analyze the outcome of bifocal and trifocal bone distraction technique on the tibial bony defect. A comprehensive literature search was performed using PubMed, Google Scholar, and Cochrane library. The inclusion criteria were any studies about comparison between bifocal bone transports with trifocal bone transport in management of large tibial bone defect. The outcomes assessed includes external fixation index, duration of regenerate consolidation, lengthening speed, bone transport distance, and operating time. Two studies reported shorter external fixation index in total of 57 fractures in the trifocal group and 61 fractures in the bifocal group. The meta-analysis showed significant difference in external fixation index between the two groups (Figure 1; RR=-44.37; 95% CI 73.73-15.01; p<0.0001) with significant heterogeneity (Chi square=11.38, p=0.0007); I2: 91%. Although only two studies were compared, both studies had almost similar subjects, and shown that trifocal bone transport technique had faster external fixator index compared to the bifocal bone transport group in the setting of severe bone loss in tibial fracture.

Risk factors associated with infection recurrence of posttraumatic osteomyelitis treated with Ilizarov bone transport technique—a retrospective study of 149 cases

Background Post-traumatic tibial osteomyelitis is considered as complex clinical problem due to its unique characteristics such as prolonged course, multi-staged treatment and high recurrence rate. The purpose of this study is to identify and analyze the causes and risk factors associated with infection recurrence of tibial osteomyelitis treated with Ilizarov technique. Methods From January 2011 to January 2019, a total of 149 patients with post-traumatic tibial osteomyelitis treated with Ilizarov bone transport technique were included in this study. Demographic and clinical data were collected and analyzed. Univariate analysis and logistic regression analysis were used to analyze the factors that may affect the recurrence or reinfection of post-traumatic tibial osteomyelitis after treated with Ilizarov bone transport technique. Results All included patients were successfully followed up with an average of 37.5 month (18–78 month), among them, 17 patients (11.4%) occurred with recurrence or reinfection of tibial osteomyelitis in which 2 cases were in distraction area and 15 cases in docking site. Among them, 5 patients were treated successfully with appropriate intravenous antibiotic, the remaining 12 patients were intervened by surgical debridement or bone grafting after debridement. Univariate analysis showed that Pseudomonas aeruginosa infection, bone exposure, number of previous operations (> 3 times), blood transfusion during bone transport surgery, course of osteomyelitis > 3 months, diabetes was associated with recurrence or reinfection of postoperative tibial osteomyelitis. According to the results of logistic regression analysis, Pseudomonas aeruginosa infection, bone exposure, and the number of previous operations (> 3 times) are risk factors for recurrence or reinfection of posttraumatic tibial osteomyelitis treated with Ilizarov bone transport technique, with odds ratios (OR) of 6.055, 7.413, and 1.753, respectively. Conclusion The number of previous operations (> 3 times), bone exposure, and Pseudomonas aeruginosa infection are risk factors for infection recurrence of posttraumatic tibial osteomyelitis treated with Ilizarov bone transport technique.

Reconstruction of Long Segmental Tibial Bone Defects Caused by Infection using the Bifocal or Trifocal Bone Transport Technique with Monolateral Rail External Fixator

Background: The purpose of this study was to evaluate the clinical effectiveness and determine the differences, if any, between trifocal and bifocal bone transport technique in the reconstruction of long segmental tibial bone defects caused by infection using a monolateral rail external fixator. Methods: A total of 53 consecutive patients with long segmental tibial bone defects caused by infection and treated by monolateral rail external fixator in our department were retrospectively collected and analyzed from January 2013 to April 2019, including 39 males and 14 females with an average age of 38.8±12.4 years (range 19 to 65 years). 32 patients were treated by bifocal bone transport (BFT) technique, and the other 21 patients were managed by trifocal bone transport (TFT) technique. The demographic data, operation duration, docking time, external fixation time, and external fixation index were documented and analyzed. Difficulties that occur during the treatment were classified according to Paley. The clinical outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov criteria (ASAMI) at the last clinical visit.Results: All patients achieved an infection-free union finally, and there was no significant difference between the two groups in demographic data and both ASAMI bone and functional scores (P>0.05). The mean defect size and operation duration in TFT (9.4±1.5 cm, 161.9±8.9 minutes) were larger than that in BFT (7.8±1.8 cm, 122.5±11.2 minutes) (P<0.05). The mean docking time, external fixation time, and external fixation index in TFT (65.9±10.8 days, 328.0±57.2 days, 34.8±2.1 days/cm) were all less than those in BFT (96.8±22.6 days, 474.5±103.2 days, 60.8±1.9 days/cm) (P<0.05). Difficulties and complications were more prevalent in the BFT group, while less in the TFT group (P<0.05). Conclusions: Both the trifocal and bifocal bone transport technique in the reconstruction of long segmental tibial bone defects caused by infection using a monolateral rail external fixator achieve satisfactory clinical outcomes. The trifocal bone transport technique can significantly decrease the docking time, external fixation time, external fixation index, difficulties, and complications compared with the bifocal bone transport technique.

Treatment of diaphyseal forearm defects caused by infection using Ilizarov segmental bone transport technique

Background The Ilizarov segmental bone transport technique can be applied in the reconstruction of the bone defects with less invasive fashion and more versatility compared to other methods, while most studies were focused on the lower extremity. The purpose of this study was to evaluate the effectiveness of the Ilizarov segmental bone transport technique in the treatment of diaphyseal forearm bone defects caused by infection. Methods This study included 12 patients with diaphyseal forearm bone defects caused by infection, who underwent bone transport procedures using the monolateral external fixator at our institution from January 2010 to January 2018, including 10 males and 2 females with a mean age of 39 years (range 23–57 years). Patient’s demographic data and clinical outcomes at least two years follow-up after removing the external fixator were collected and retrospectively analyzed. The functional results were evaluated by the questionnaire of Disability of Arm, Shoulder and Hand (DASH) and the modified Mayo wrist score (MWS) at the final follow-up. Results There were 10 radii and 2 ulnae bone transport procedures collected. The average defect size was 5.1 cm (4-6.5 cm). All patients were successfully followed up with a mean period of 28.2 months (24 to 36 months) and achieved infection-free union. There was no recurrence of infection observed. The mean external fixation time was 232.6 days (182 to 276 days), and the mean external fixation index was 46.3 days/cm (40.9 to 61.8 days/cm). The mean DASH score was 30.6(18 to 49) preoperative, while 13.8 (5 to 26) at the final follow-up. The average modified MWS improved from 68.8 (55 to 80) pre-operatively to 83.8 (65 to 90) at the final follow-up. All the differences between the preoperative and final scores were statistically significant (p < 0.05). Almost all the patients achieved satisfactory clinical outcomes and were able to perform activities of daily living. Conclusions Ilizarov segmental bone transport technique is an alternative and effective method for the treatment of diaphyseal forearm bone defects caused by infection, and this method acquired satisfactory clinical outcomes.

A New Parameterized Model for Determining Quality of Online Video Service Using Modern H.265/HEVC and VP9 Codecs

This paper describes a new measurement method (VS model) for determining the quality of online video services relying on modern H.265/HEVC and VP9 codecs. The said method has been developed on the basis of VQuad-HD curves (according to ITU-T J.341). This model does not refer to signal analysis, but protocol analysis instead. The parameters used are: type of video codec, encoding rate, transport technique, packet loss and burst size. The method may be implemented quickly and easily, which is one of the great advantages when using this method to measure QoS.